Clinical/Sonographic Assessment and Management of Calcific Tendinopathy of the Shoulder: A Narrative Review

Exploring Metabolic Mechanisms in Calcific Tendinopathy and Shoulder Arthrofibrosis: Insights and Therapeutic Implications

Rotator cuff calcific tendinopathy and arthrofibrosis of the shoulder (adhesive capsulitis) are debilitating musculoskeletal disorders that significantly impact joint function and impair quality of life. Despite its high prevalence and common clinical presentation, the metabolic mechanisms underlying these conditions characterized by pain, and reduced mobility, remain poorly understood. This review aims to elucidate the role of metabolic processes implicated in the pathogenesis of calcific tendinopathy and shoulder arthrofibrosis. We will be focusing on the mechanistic role of how these processes contribute to disease progression and can direct potential therapeutic targets. Calcific tendinopathy is marked by aberrant calcium deposition within tendons, influenced by disrupted calcium and phosphate homeostasis, and altered cellular responses. Key molecular pathways, including bone morphogenetic proteins (BMPs), Wnt signaling, and transforming growth factor-beta (TGF-β), play crucial roles in the pathophysiology of calcification, calcium imbalance, and muscle fibrosis. In contrast, shoulder arthrofibrosis involves excessive collagen deposition and fibrosis within the shoulder joint capsule, driven by metabolic dysregulation and inflammation. The TGF-β signaling pathway and inflammatory cytokines, such as interleukin-6 (IL-6), are central to the fibrotic response. A comparative analysis reveals both shared and distinct metabolic pathways between these conditions, highlighting the interplay between inflammation, cellular metabolism, extracellular matrix remodeling, calcific deposition, and calcium migration to the glenohumeral joints, resulting in adhesive capsulitis, thereby providing insights into their pathophysiology. This review discusses current therapeutic approaches and their limitations, advocating for the development of targeted therapies that address specific metabolic dysregulations. Future therapeutic strategies focus on developing targeted interventions that address the underlying metabolic dysregulation, aiming to improve patient outcomes and advance clinical management. This review offers a comprehensive overview of the metabolic mechanisms involved in calcific tendinopathy and shoulder arthrofibrosis, providing a foundation for future research and therapeutic development.

Musculoskeletal disorders in padel: from biomechanics to sonography

Padel is a racket sport, combining high-frequency and low-intensity athletic gestures, that has been gaining growing scientific interest in recent years. Musculoskeletal injuries are very common among padel players with an incidence rate of 3 per 1000 h of training and 8 per 1000 matches. To the best of our knowledge, a comprehensive collection describing the most common sonographic findings in padel players with musculoskeletal injuries is lacking in the pertinent literature. In this sense, starting from the biomechanical features of padel-specific gestures we have reported the ultrasonographic patterns of most frequent injuries involving the upper limb, the trunk, and the lower limb. Indeed, comprehensive knowledge of the biomechanical and clinical features of musculoskeletal injuries in padel is paramount to accurately perform a detailed ultrasound examination of the affected anatomical site. So, the present investigation aims to provide a practical guide, simple and ready-to-use in daily practice, to optimize the sonographic assessment of padel players by combining it with the clinical findings and the biomechanical features of athletic gestures.

Clinical features in rotator cuff calcific tendinopathy: A scoping review

Introduction

The main goal of this scoping review is to highlight the clinical features of subjects with rotator cuff calcific tendinopathy (RCCT), in order to identify and map this condition clinical criteria, and thus to be able to hypothesize such pathology before imaging investigations.

Methods

Four databases were consulted up to January 2023. The obtained results were reported following the PRISMA-ScR and the Joanna Briggs Institute reviewer's manual was used as guideline for conducting the review. No time and geographical restrictions were applied.

Results

A total of 851 records have been identified, with 50 studies meeting the inclusion criteria. Subjects with RCCT mostly reported nightly, acute and severe pain with spontaneous onset. Symptoms were mostly unilateral. Subjects were mostly women aged between 30 and 60. Deficit in active and passive range of motion was reported, mainly during abduction and forward flexion. Endocrine and metabolic disorders were described as comorbidity, in particular diabetes and thyroid disorders.

Conclusion

In this scoping review, the most relevant RCCT clinical features were detected. These clinical criteria, predictive for shoulder RCCT, can be crucial to help all clinicians suspect this musculoskeletal disease early and with certainty, thus allowing for an appropriate and prompt diagnosis path.

Level of evidence

III.

Shoulder structures and strength in competitive preadolescent swimmers: A longitudinal ultrasonographic study

BACKGROUND

Repetitive shoulder movements during competitive training may cause changes in the strength of periarticular shoulder structures in preadolescent swimmers.

OBJECTIVE

To prospectively determine the effects of training on shoulder periarticular structures and muscle strength in preadolescent swimmers.

DESIGN

Prospective cohort study.

SETTING

Community-based natatorium.

PARTICIPANTS

Twenty-four preadolescent swimmers aged 10-12 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measurements were repeated in three periods as preseason, midseason, and postseason. Ultrasonographic measurements (supraspinatus tendon thickness, humeral head cartilage thickness, deltoid muscle thickness, and acromiohumeral distance) were performed using a portable device and a linear probe. Shoulder (flexion, extension, abduction, internal and external rotation) and back (serratus anterior, lower, and middle trapezius) isometric muscle strength were measured with a handheld dynamometer.

RESULTS

Supraspinatus tendon thickness and acromiohumeral distance were similar in all periods (all p > .05); however, deltoid muscle and humeral head cartilage thicknesses increased throughout the season (p = .002, p = .008, respectively). Likewise, whereas shoulder muscle strength increased (all p < .05), back muscle strength was similar in all periods (all p > .05).

CONCLUSIONS

In preadolescent swimmers, acromiohumeral distance and supraspinatus tendon thickness seem to not change; but humeral head cartilage and deltoid muscle thicknesses as well as shoulder muscle strength increase throughout the season.

Ultrasound imaging in crystal arthropathies: a pictorial review

OBJECTIVE

The prevalence of crystal arthropathies in the general population is rising. The purpose of this pictorial study is to describe the sonographic elements of the most prevalent crystal arthropathies by emphasizing particular sonographic findings using illustrative images and cases while considering technical details and common pitfalls.

METHODS

Using established recommendations, specialists in the fields of sonography and crystal arthropathies agreed by consensus on the unique ultrasound signs associated with each of the conditions.

RESULTS

Gout, calcium pyrophosphate deposition arthropathy, and hydroxyapatite arthropathy are the three most prevalent crystal arthropathies. Today's high-resolution sonography enables reliable evaluation of the underlying crystal deposits, post-inflammatory changes, and a precise description of joint inflammation.

CONCLUSIONS

High-prevalence crystal arthropathies are reliably detectable by ultrasound with current ultrasound equipment. It is necessary to have extensive ultrasound training, know specific sonographic findings, and understand all possible differential diagnoses for disorders affecting the musculoskeletal system.

Long-Term Outcomes of Ultrasound-Guided Hydrodistension for Adhesive Capsulitis: A Prospective Observational Study

Ultrasound-guided hydrodistention has been established as an effective minimally invasive treatment option for glenohumeral joint adhesive capsulitis (AC). Nonetheless, the long-term outcomes of the procedure have not yet been established. A total of 202 patients with AC were prospectively recruited and followed up for a total of 2 years. Pain and functionality were assessed with the use of the visual analogue scale (VAS) and the disabilities of the arm, shoulder, and hand (DASH) score, respectively, at the beginning and the end of the follow-up period. The relapse of AC over the 2-year period and the effect of diabetes were also evaluated in the treatment cohort. The Mann-Whitney U test was used to compare mean scores at the two time points, and Cox survival analysis and χ2 test were used to assess the effect of diabetes on AC relapse. VAS and DASH scores were significantly lower at 2 years compared with the beginning of the follow-up period (p < 0.001). Diabetes was diagnosed in 38/202 patients (18.8%) and was found to be significantly associated with recurrence of the disease (p < 0.001). In conclusion, in this observational study, we have demonstrated that ultrasound-guided hydrodistention is linked to excellent long-term outcomes for the treatment of AC, which are significantly worse in patients with diabetes.

Ultrasound Guided Arthroscopic Removal of Calcific Tendonitis: A Minimum of 2-Year Followup

Background: We have developed a novel technique for managing rotator cuff calcific tendonitis, involving arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance. While we have demonstrated encouraging results at six-month follow-up, the medium-term outcomes and the long-term outcomes of this technique at 2 years or beyond are unknown. The aim of this paper was to determine if this technique was successful in resolving symptoms after two years and beyond. Study Design: Retrospective Cohort Study. Methods: Patients who underwent arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance by a senior surgeon were evaluated using patient-rated pain scores and functional status with the use of the Likert scales and via examiner-rated shoulder range-of-motion and strength at the pre-operative visit, at 1, 6, 12, and 24 weeks post-operatively, and long-term at a mean of 249 weeks after surgery. Results: At a mean follow-up period of 4.8 years (range, 2-10 years), 31 patients (33 shoulders) experienced significant improvement in the severity of pain at rest, with overhead activities, and during sleep compared to their pre-operative presentation (p < 0.001). The patient experienced less frequent pain during activities and sleep, and a decreased frequency of extreme pain (p < 0.001). Passive range of abduction (p = 0.003), forward flexion (p < 0.001), and supraspinatus strength (p = 0.018) improved compared to the presurgical presentation. Out of 27 patients, 24 patients (89%) had complete resolution of calcific tendonitis, and 26 patients (96%) had an intact rotator cuff. Conclusion: Arthroscopic debridement of calcific tendonitis with localization assistance from a breast biopsy needle under ultrasound guidance was very effective. Patients had significant pain relief, improved range of motion, and a reduction in stiffness at a mean post-operative period of 4.8 years. Patients had a significant reduction in residual calcification, and rotator cuff integrity was largely preserved by long-term follow-up. What is known about this subject: Calcific tendonitis of the rotator cuff is one of the most painful and debilitating disorders of the shoulder. This condition is characterized by the deposition of calcium-phosphate crystals within the rotator cuff tendons. Arthroscopic debridement and excision of rotator cuff calcifications have proven to be efficacious treatments with regards to clinical and functional outcomes in the short and medium term. Identifying the calcific lesion intra-operatively, however, can prove to be challenging. Furthermore, inadequate excision of the calcific deposit has been shown to have poorer clinical outcomes. We designed a technique that utilizes the assistance of ultrasound to guide a localization-biopsy wire to the calcific lesion. This technique aids in precisely identifying the location of the lesion intra-operatively to optimize accuracy in removing the maximum amount of calcific deposit possible. A short-term follow-up study by us has demonstrated successful outcomes with regards to the return of function and relief of pain. However, there have been no studies evaluating the effectiveness of this particular technique beyond six months. What this study adds to current knowledge: At a mean of 4.8 years, arthroscopic debridement of calcific tendonitis, using our technique, was successful in relieving the severity and frequency of pain with overhead activities, pain at rest, and pain during sleep, as well as improving range of motion.